Diversion of opioid analgesics from their intended uses in pain control to improper uses has become a wide-scale problem, resulting in opioid overdose deaths and addiction. According to a recent review, the most common form of diversion is the transfer of opioid analgesics by patients with a proper prescription to family members or friends trying to self- medicate.
While this specific issue can only be solved by educating patients on the harm of sharing these powerful drugs, there are systems in place to help mitigate other methods of opioid diversion.
The term “doctor shopping” has been used to identify the type of diversion which occurs among patients who feign pain to acquire prescribe opioids from multiple physicians with the goal of maintaining their addiction. Diversion of prescription opioids through doctor shopping can be mitigated by the participation of prescribers in their respective state Prescription Drug Monitoring Programs (PDMPs).
PDMPs are electronic databases that collect information on the prescribing and dispensing of opioids and other controlled prescription drugs. They are designed to monitor information pertaining to suspected abuse of controlled substances. The dispenser (pharmacy) enters prescription data into a central database within three days after dispensing the medication. Along with basic patient identifying information (name, date of birth, gender, address), the prescription data entered should also include:
- Prescription number
- Date prescription was issued
- Date prescription was filled
- Whether the prescription was new or a refill
- Number of refills ordered
- Metric quantity of drug dispensed
- Days’ supply of drug dispensed
The effectiveness of PDMPs was recently examined. The review can be found at: Volkow ND, McLellan T. “Opioid abuse in chronic pain – misconceptions and mitigation strategies. Review article.” New Eng J Med 2016; 374:1253-63.
According to the authors of the review, there are a number of issues that interfere with the success of the PDMP system:
- Use of PDMPs by prescribers has been inconsistent
- Not all PDMPs share information across states
- Access to PDMP data requires a computer that is separate from the one used to access electronic heath records
- There is no mandatory requirement for the prescriber to consult with the PDMP database before prescribing a controlled substance
In 2012, the authors of another study described what they called the ideal PDMP. The study can be found at: Perrone J, Nelson SL. “Medication reconciliation for controlled substance – an “ideal” prescription-drug monitoring program.” N Engl J Med 2012; 366: 2341-43.
The authors of this study found there to be a number of reasons that prescribers are not using their available PDMP:
- Time restraints
- Feeling that it would not change practice for the patient
- Difficult navigation
- Forgetting the password
- Never having applied for access
- Lack of computer availability.
There are concerns that a PDMP is burdensome for prescribers and dispensers and may inappropriately reduce the amount of opioid analgesic prescribed.
An ideal PDMP
In their introduction, the authors of the 2012 study stated that between 1997 and 2007, the use of prescription opioids more than quadrupled. The risk of opioid overdoses is correlated with the quantity of these drugs being prescribed. From the physician’s viewpoint, new patients with chronic pain can be difficult to evaluate without a comprehensive pain-management record.
An ideal PDMP should alert its users to signs of aberrant or illegal drug procurement behavior. The PDMP should monitor all controlled substances that fall within DEA Schedule II (e.g., oxycodone, hydrocodone), Schedule III (e.g., codeine-acetaminophen combination drugs), Schedule IV (e.g., benzodiazepines), Schedule V (e.g., low-dose codeine cough suppressants), and stimulants such as amphetamine and methylphenidate.
Other characteristics of the ideal PDMP include:
- Easy access to the database
- Real-time updates to the database
- Mandatory pharmacy reporting
- Interstate accessibility
Improving use of PDMPs
For PDMPs to be a useful tool in mitigating diversion of opioids and other controlled substances by identifying doctor shoppers, research is needed to optimize how prescribers use PDMPs and how the clinicians and patients respond to the data.
There is an interesting report out of Oregon describing the use of PDMPs in a statewide survey. The report contains some valuable information which is useful in providing a beginning to this process. It is available at: Irvine JM, et al. “Who uses a prescription drug monitoring program and how? Insights from a statewide survey of Oregon clinicians.” The Journal of Pain 2014; 15: 747-755.
In their introduction, the authors state that little is known about the characteristics of clinicians who register and use PDMPs and of those who choose not to register. The goal of this study was to examine differences between PDMP users and nonusers and how clinicians in various specialties use PDMPs in practice.
The Oregon data provides a snapshot of PDMP use and functionality in general, since Oregon’s PDMP is similar to many others. Pharmacies are required to upload Schedule II through IV controlled substances at least weekly, and clinicians are able to access information at any time via the Internet.
For the study, the authors surveyed a random sample of Oregon healthcare providers, with 1,065 respondents. The PDMP registry of clinicians was used to define high- and low-frequency user groups. The break between high- and low-frequency users was based on actual usage observed in the PDMP over a three-month period. High-frequency users were defined as those who had queried four or more times in that interval. Low-frequency users were defined as those making less than four queries in that time.
Oregon study results
- Response to the survey included 358 in the high-frequency PDMP users, 261 low-frequency users, and 439 nonusers.
- Clinician types (users and nonusers) were as follows:
- Physicians: 394 (65%) users; 196 (45.6%) nonusers
- Nurse practitioners: 99 (16.3%) users; 107 (24.9%) nonusers
- Dentists: 40 (6.6%) users; nonusers 91 (21.2%)
- Physician assistants: 59 (9.7%) users; 23 (5.4%) nonusers
- In terms of specialties, the user group was heavily represented by those practicing in emergency medicine, pain and addiction, and primary care.
- In contrast, nurse practitioners, surgeons, dentists, and psychiatrists were more heavily represented in the nonuser group.
- Registered users of PDMPs reported prescribing all classes of controlled substances more often than non-registrants. The prescribed controlled substances included opioids, benzodiazepines, amphetamine-like drugs, and sleep medications.
- Of the dentist respondents, 70% prescribed opioids at least weekly, however, only 39% had registered to use the PDMP.
- Among users of PDMPs, 95% reported accessing the PDMP when they suspected a patient of abuse or diversion, but fewer than half would check it for every new patient or every time they prescribed a controlled drug.
- Nearly all PDMP users reported that they discussed worrisome PDMP data with patients, 54% reported making mental health or substance abuse referrals, and 36% reported sometimes discharging patients from the practice.
- Respondents reported frequent patient denial or anger and only occasional requests for help with drug dependence.
The findings in the Oregon study suggest that the current way PDMPs are used may not promote optimal care, particularly for drug dependence or abuse. It also reveals how much research is still needed to begin to effectively use PDMP data to detect drug abuse and misuse. Further investigation into how clinicians discuss PDMP with patients; the actions they take in response to suspected abuse, misuse, or diversion; and the subsequent patient responses and outcomes is needed to identify promising practices for migration of drug diversion.
Richard L. Wynn, BS Pharm, PhD, is professor of pharmacology at the Baltimore College of Dental Surgery, Dental School, University of Maryland Baltimore.